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ERYSIPELAS (?) IN A YOUNG CHILD.
921
canI
now resolved itself into a discussion which have little interest for your readers. I am, Sirs, yours faithfully, SAMUEL SLOAN. Glasgow, Sept. 9th, 1907.
that it has
A CASE OF SELF-INDUCED (?) ABORTION.
paper. I suppose a good many of these cases had an abscess for several days ; at any rate, I frequently get cases at the Children’s Hospital who are brought up from seven to ten days after the onset of the illness with large localised abscesses. These are opened at once, but it is hardly looked upon in the sense of the " immediate" operation. The removal of the appendix at this stage must certainly add to the
danger of the operation, as it risks infection of the To the Editors of THE LANCET. cavity when the patient’s tissues have, after much SIRS,—In Dr. A. B. M. Thomson’s short paper on the above peritoneal walled it off into a position of safety. I know trouble, subject in your issue of Sept. 7th he says,’’ The question which authorities differ on this point but I have never regretted called for decision was whether this was in reality a case of not removing the appendix in opening a localised abscess. self-induced abortion. Is it possible for a woman to introClass 4.-As in Class 3, there is no guide to the time of duce into her uterus, without causing injury to the vaginal the various operationE’, still, as they were suppurating cases, walls or to the os, a straight rigid rod four inches in are hardly likely to have been very early ones. they length?" It may interest him and some of your other I am not at the early operation done within a few readers to hear of a remarkable case in point. Some years hours of thecavilling onset of appendicitis, but I do think that this ago, I think it was in the " seventies," I had a patient under series of 100 cases with four (or seven) deaths is gravely my care who confessed to me, and I had no reason to doubt fallacious as a proof of the benefits of early operative treather word, that she had brought on abortion on herself ment when interval cases are included, and when we get no thirty-five (35) times1 The instrument she used was a bone guide in the majority of the cases as to how soon after the knittiicg-needle. She used to squat down and, finding the onset the operation was performed. Instead of the deathos, pass the knitting-needle into the uterus. She was so rate being reduced to 4 per 100 as a result of the immediate regular in her periods that she knew at once when she had operation, it must be-well, perhaps Mr. Spencer will give us conceived and immediately proceeded to operate ; and a more accurately analysed list. though on several occasions she had rather severe hsemorI am, Sirs, yours faithfully, rhage, yet, as far as I remember, she was never in any JOSEPH CUNNING. W., Upper Wimpole-street, Sept. 14th, 1907.JOSEPH serious danger ; a rather remarkable result in those preaseptic days.-I am, Sirs, yours faithfully, HEYWOOD HEYWQOD SMITH. Welbeck-street, W., Sept. 19th, 1907. IN A YOUNG CHILD. ERYSIPELAS
(?)
RESULTS IN APPENDICITIS TREATED BY THE IMMEDIATE AND COMPLETE OPERATION. To the Edito’1’s
of THE LANCET.
Yi9 the Editors of THE LANCET. SIRS,-The following note may be of interest, as I can find but few recorded cases of a similar nature. The patient was a little girl, aged five years, who was brought to my house about a week ago with a sharply-defined bright-red patch on the right cheek. I told her mother that had it not been for the child’s age, when such an affection was very unusual, I should certainly have diagnosed the case The child’s skin was hot and as commencing erysipelas. the was 101’ 40 F., and there was distinct dry, temperature albuminuria. I prescribed a simple febrifuge and asked that I might be informed if there should be any further developments. Two days later I was asked to see the patient at her own home, where I found her presenting all the appearances of a typical case of facial erysipelas. The face was swollen to the extent of being unrecognisable ; there was marked oedema of the eyelids ; and there was a well-marked line of demarcation between the erysipelatous and the healthy skin. Since then the case has run an uneventful course, the redness becoming daily less marked and the temperature gradually falling from 102’ 8° to within a point or two of normal. Treatment has been on the usual lines. There was no history of any injury, there was no affection of the ear or throat, and the child’s teeth were in good order. Her mother told me that when I first saw her she had just returned from a country holiday but she could not think of possible exposure to infection. The drains of the house any in which they stayed were, so far as she could tell, satis-
SiRS,-The controversy whether it is better to operateI within the first few hours of the onset of appendicitis orr whether it is better to wait until there is some definite callL for operation has gone on for many years. Mr. W. G. Spencer is to be congratulated upon having at consecutive seriep of 100 cases of appendicitis (published in1 THE LANCET of Sept. 14th, p. 770) with but seven deaths, , S or four if we exclude the three cases who had other lesions But if we accept the title of his paper and hisS as well. concluding paragraph-viz., "that it has been possible to3 diagnose and to operate on 100 cases of appendicitis, with a loss, when the appendicitis was the sole disease, of onlyY four, a result which removes the various objections that haves been raised to the method "-it will be seen that those ofz t us who have an open mind upon this question can derive but little instruction upon this important point. lf it is truee that the immediate and complete operation is responsible forr so low a death-rate as 4 (or 7) per 100 cases, then every Y right-thinking surgeon should adopt the immediate treat-jment. But let us look more closely at these 100 cases. Class 1.-37 cases; no deaths. Admirable. But thesee " Ir are defined as cases in the interval between the attacks, or factory. acute and subacute cases." How many of these weree early I shall be glad if any of your readers who have met with " interval"cases is not stated, but it seriously reduces thee similar cases at such an early age will favour me with a is 100 cases submitted to ,. immediate"treatment, unless few facts concerning them, and with suggestions as to their " ir immediate " only means as soon as they came under probable cause.-I am, Sirs, yours faithfully, is Mr. Spencer’s care." No good surgeon in these days expects T. R. C.M. Edin. R. HENDERSON, HENDERSON, M.B., C.M, n otherwise than to obtain equally satisfactory figures from Bedford Hill, Balham, S.W., Sept. 15th, 1907. this type of case whether they are done immediately or in a week or two. Then " subacute" is a term open to misARTHROPATHY IN RÖTHELN. understanding. Does it mean that they were recognised as very mild cases, or were they recovering from acute attacks, To the Editors of THE LANCET. and if the latter, how ’’ immediate " was their treatment ?1 Mr. Spencer says, "some of these cases would have recovered SiRS,-While the nature of rheumatoid arthritis is under without operation, others would have become rapidly worse discussion I should like to place on record the occurrence of had the operation been delayed " ; but as he dispensed an arthropathy during the course of rotheln. The patient with drainage in all, he evidently did not think so badly of was a young man, aged 24 years, who, after a few days of them. sore-throat, stiff neck, malaise, and moderate fever, developed Class 2.-These are labelled gangrenous and perforating a rash having the distribution and appearance of German appendicitis and stibacute appendicitis. 31 cases; foux measles and accompanied by an enlargement of superficial deaths. All will agree that the sooner gangrenous and per. glands, notably those of the neck. Before the exanthem forating cases are operated upon the better, but why pui had faded the patient began to complain of stiffness and subacute cases into this class ?1 How many of these weIE tenderness in the knees and ankles, and soon all the intersubacute, and, if so, how early were they operated upon7 phalangeal joints of the fingers presented the spindle-like Class .—Cases of suppurating appendicitis treated b swelling commonly seen in rheumatoid arthritis. There was removal of the appendix and drainage. Again comes th. no exacerbation of temperature and neither cardiac nor other question as to how elastic a term is the " immediate " in this complication, and a fortnight from the appearance of the
canI
now resolved itself into a discussion which have little interest for your readers. I am, Sirs, yours faithfully, SAMUEL SLOAN. Glasgow, Sept. 9th, 1907.
that it has
A CASE OF SELF-INDUCED (?) ABORTION.
paper. I suppose a good many of these cases had an abscess for several days ; at any rate, I frequently get cases at the Children’s Hospital who are brought up from seven to ten days after the onset of the illness with large localised abscesses. These are opened at once, but it is hardly looked upon in the sense of the " immediate" operation. The removal of the appendix at this stage must certainly add to the
danger of the operation, as it risks infection of the To the Editors of THE LANCET. cavity when the patient’s tissues have, after much SIRS,—In Dr. A. B. M. Thomson’s short paper on the above peritoneal walled it off into a position of safety. I know trouble, subject in your issue of Sept. 7th he says,’’ The question which authorities differ on this point but I have never regretted called for decision was whether this was in reality a case of not removing the appendix in opening a localised abscess. self-induced abortion. Is it possible for a woman to introClass 4.-As in Class 3, there is no guide to the time of duce into her uterus, without causing injury to the vaginal the various operationE’, still, as they were suppurating cases, walls or to the os, a straight rigid rod four inches in are hardly likely to have been very early ones. they length?" It may interest him and some of your other I am not at the early operation done within a few readers to hear of a remarkable case in point. Some years hours of thecavilling onset of appendicitis, but I do think that this ago, I think it was in the " seventies," I had a patient under series of 100 cases with four (or seven) deaths is gravely my care who confessed to me, and I had no reason to doubt fallacious as a proof of the benefits of early operative treather word, that she had brought on abortion on herself ment when interval cases are included, and when we get no thirty-five (35) times1 The instrument she used was a bone guide in the majority of the cases as to how soon after the knittiicg-needle. She used to squat down and, finding the onset the operation was performed. Instead of the deathos, pass the knitting-needle into the uterus. She was so rate being reduced to 4 per 100 as a result of the immediate regular in her periods that she knew at once when she had operation, it must be-well, perhaps Mr. Spencer will give us conceived and immediately proceeded to operate ; and a more accurately analysed list. though on several occasions she had rather severe hsemorI am, Sirs, yours faithfully, rhage, yet, as far as I remember, she was never in any JOSEPH CUNNING. W., Upper Wimpole-street, Sept. 14th, 1907.JOSEPH serious danger ; a rather remarkable result in those preaseptic days.-I am, Sirs, yours faithfully, HEYWOOD HEYWQOD SMITH. Welbeck-street, W., Sept. 19th, 1907. IN A YOUNG CHILD. ERYSIPELAS
(?)
RESULTS IN APPENDICITIS TREATED BY THE IMMEDIATE AND COMPLETE OPERATION. To the Edito’1’s
of THE LANCET.
Yi9 the Editors of THE LANCET. SIRS,-The following note may be of interest, as I can find but few recorded cases of a similar nature. The patient was a little girl, aged five years, who was brought to my house about a week ago with a sharply-defined bright-red patch on the right cheek. I told her mother that had it not been for the child’s age, when such an affection was very unusual, I should certainly have diagnosed the case The child’s skin was hot and as commencing erysipelas. the was 101’ 40 F., and there was distinct dry, temperature albuminuria. I prescribed a simple febrifuge and asked that I might be informed if there should be any further developments. Two days later I was asked to see the patient at her own home, where I found her presenting all the appearances of a typical case of facial erysipelas. The face was swollen to the extent of being unrecognisable ; there was marked oedema of the eyelids ; and there was a well-marked line of demarcation between the erysipelatous and the healthy skin. Since then the case has run an uneventful course, the redness becoming daily less marked and the temperature gradually falling from 102’ 8° to within a point or two of normal. Treatment has been on the usual lines. There was no history of any injury, there was no affection of the ear or throat, and the child’s teeth were in good order. Her mother told me that when I first saw her she had just returned from a country holiday but she could not think of possible exposure to infection. The drains of the house any in which they stayed were, so far as she could tell, satis-
SiRS,-The controversy whether it is better to operateI within the first few hours of the onset of appendicitis orr whether it is better to wait until there is some definite callL for operation has gone on for many years. Mr. W. G. Spencer is to be congratulated upon having at consecutive seriep of 100 cases of appendicitis (published in1 THE LANCET of Sept. 14th, p. 770) with but seven deaths, , S or four if we exclude the three cases who had other lesions But if we accept the title of his paper and hisS as well. concluding paragraph-viz., "that it has been possible to3 diagnose and to operate on 100 cases of appendicitis, with a loss, when the appendicitis was the sole disease, of onlyY four, a result which removes the various objections that haves been raised to the method "-it will be seen that those ofz t us who have an open mind upon this question can derive but little instruction upon this important point. lf it is truee that the immediate and complete operation is responsible forr so low a death-rate as 4 (or 7) per 100 cases, then every Y right-thinking surgeon should adopt the immediate treat-jment. But let us look more closely at these 100 cases. Class 1.-37 cases; no deaths. Admirable. But thesee " Ir are defined as cases in the interval between the attacks, or factory. acute and subacute cases." How many of these weree early I shall be glad if any of your readers who have met with " interval"cases is not stated, but it seriously reduces thee similar cases at such an early age will favour me with a is 100 cases submitted to ,. immediate"treatment, unless few facts concerning them, and with suggestions as to their " ir immediate " only means as soon as they came under probable cause.-I am, Sirs, yours faithfully, is Mr. Spencer’s care." No good surgeon in these days expects T. R. C.M. Edin. R. HENDERSON, HENDERSON, M.B., C.M, n otherwise than to obtain equally satisfactory figures from Bedford Hill, Balham, S.W., Sept. 15th, 1907. this type of case whether they are done immediately or in a week or two. Then " subacute" is a term open to misARTHROPATHY IN RÖTHELN. understanding. Does it mean that they were recognised as very mild cases, or were they recovering from acute attacks, To the Editors of THE LANCET. and if the latter, how ’’ immediate " was their treatment ?1 Mr. Spencer says, "some of these cases would have recovered SiRS,-While the nature of rheumatoid arthritis is under without operation, others would have become rapidly worse discussion I should like to place on record the occurrence of had the operation been delayed " ; but as he dispensed an arthropathy during the course of rotheln. The patient with drainage in all, he evidently did not think so badly of was a young man, aged 24 years, who, after a few days of them. sore-throat, stiff neck, malaise, and moderate fever, developed Class 2.-These are labelled gangrenous and perforating a rash having the distribution and appearance of German appendicitis and stibacute appendicitis. 31 cases; foux measles and accompanied by an enlargement of superficial deaths. All will agree that the sooner gangrenous and per. glands, notably those of the neck. Before the exanthem forating cases are operated upon the better, but why pui had faded the patient began to complain of stiffness and subacute cases into this class ?1 How many of these weIE tenderness in the knees and ankles, and soon all the intersubacute, and, if so, how early were they operated upon7 phalangeal joints of the fingers presented the spindle-like Class .—Cases of suppurating appendicitis treated b swelling commonly seen in rheumatoid arthritis. There was removal of the appendix and drainage. Again comes th. no exacerbation of temperature and neither cardiac nor other question as to how elastic a term is the " immediate " in this complication, and a fortnight from the appearance of the